Name
Purdue University Globle
NU566 NP I – Introduction to Primary Care for the Nurse Practitioner
Prof. Name
Date
Persistent fatigue, excessive thirst, recent weight changes, and a hemoglobin A1C of 8.5% strongly suggest that this patient’s Type 2 diabetes mellitus (T2DM) is not adequately controlled. The elevated A1C indicates that blood glucose has remained above the desired range over the preceding several months. Although uncontrolled hypertension is also an important concern and hypothyroidism can contribute to fatigue, the patient’s symptoms, medical history, and laboratory findings most strongly support poorly controlled Type 2 diabetes as the primary clinical concern. Management should focus on improving glycemic control, addressing medication intolerance and adherence, supporting lifestyle changes, managing cardiovascular risk, and ensuring appropriate follow-up and preventive screening.
The patient states:
“To be honest, I did not really want to come here today, but my daughter insisted. She knows I missed my last appointment. But I have been really tired lately.”
Her primary concern is persistent fatigue that has progressively worsened over several months.
The patient reports experiencing increasing fatigue for approximately 4–5 months. The fatigue is present throughout the day and becomes more pronounced during the afternoon. Resting for approximately 30–40 minutes provides temporary relief.
She also reports increased thirst during the same period and an approximately five-pound weight change over the previous year. The patient is postmenopausal and has missed a previous medical appointment. Her medical history includes Type 2 diabetes and hypertension.
The combination of fatigue and increased thirst in a patient with established diabetes raises concern for inadequate glycemic control. The elevated A1C further supports this concern.
The patient currently reports taking:
Atenolol 25 mg daily
Hydrochlorothiazide 25 mg daily
Metformin 2,000 mg daily
Glyburide 20 mg daily
Low-dose aspirin for cardiovascular prevention based on her reported family history
Medication-related adverse effects may be contributing to treatment adherence concerns. The patient reports gastrointestinal discomfort and diarrhea associated with metformin and glyburide. She also reports frequent nighttime urination while taking hydrochlorothiazide.
These concerns should be discussed with the prescribing clinician rather than prompting the patient to discontinue medications independently. Treatment may need to be reassessed to improve tolerability, adherence, and overall diabetes management.
The patient reports no known drug allergies.
The patient’s relevant medical history includes:
Type 2 diabetes mellitus
Essential hypertension
There is no reported history of major trauma or other chronic illnesses.
The patient has a history of:
Tonsillectomy at age 3
Appendectomy at age 12
One pregnancy approximately 34 years ago
The family history demonstrates significant cardiovascular and metabolic risk.
| Family Member | Medical History |
|---|---|
| Mother | Type 2 diabetes mellitus |
| Father | Deceased from myocardial infarction |
| Sister | Arthritis; deceased from myocardial infarction |
This history is clinically important because diabetes and hypertension are established cardiovascular risk factors, while a strong family history of myocardial infarction may further increase the patient’s overall risk.
The patient is a retired teacher with a bachelor’s degree in education. She lives independently and reports feeling safe in her home.
She denies:
Tobacco use
Alcohol consumption
Recreational drug use
The patient lives alone following her daughter’s marriage. She is not currently in a relationship and reports that she is not sexually active.
The patient reports persistent fatigue and an approximately five-pound weight change over the previous year.
She uses reading glasses for fine print. No acute visual complaints are reported.
The patient denies chest pain, palpitations, and peripheral edema.
She denies cough, shortness of breath, or other respiratory symptoms.
She denies abdominal pain, nausea, vomiting, or changes in bowel habits.
No urinary discomfort or incontinence is reported, although frequent nighttime urination is associated with hydrochlorothiazide use.
The patient denies muscle weakness or joint complaints.
She reports no numbness or weakness, and sensation is intact on examination.
The patient denies depression, anxiety, sleep disturbances, and suicidal ideation.
Breast inspection and palpation are unremarkable. The breasts are symmetrical, nipples are everted, and there are no palpable masses or nipple discharge.
| Measurement | Result |
|---|---|
| Height | 5 ft 7 in |
| Weight | 190 lb |
| BMI | 29.8 kg/m² |
| Temperature | 37.7°C |
| Blood pressure | 160/90 mmHg |
| Pulse | 80 bpm |
| Respiratory rate | 20 breaths/min |
The patient’s BMI is in the overweight range, and her blood pressure of 160/90 mmHg indicates that hypertension is not adequately controlled at this visit.
The patient appears fatigued but is pleasant, cooperative, alert, and fully oriented. Hygiene is appropriate, and she does not appear to be in acute distress.
The skin is warm, dry, and intact without visible lesions or rashes.
The head, eyes, ears, nose, and throat examination is generally unremarkable. Findings include:
No carotid bruits
No jugular venous distention
Midline trachea
No cervical lymphadenopathy
Intact extraocular movements
Pupils equal and reactive to light
Fundoscopic examination within normal limits
No apparent diabetic retinopathy
Normal ears and tympanic membranes
No sinus tenderness
The cardiovascular examination demonstrates a regular rate and rhythm with normal S1 and S2 heart sounds. No murmurs, rubs, or gallops are present. Capillary refill is approximately two seconds, peripheral pulses are 3+, and there is no peripheral edema.
Respiratory effort is normal. Breath sounds are clear bilaterally, and percussion is resonant.
The abdomen is soft, symmetrical, and nontender. No masses, guarding, or visible abnormalities are noted.
The patient has full range of motion in all extremities. Gait and balance are stable, and posture is appropriate.
Speech is clear, muscle tone is normal, sensation is intact, and cognition appears appropriate.
The patient is alert and oriented to person, place, time, and situation. Speech is soft but appropriate. Thought processes and eye contact are normal.
Most reported laboratory results are within normal limits, including the complete blood count, comprehensive metabolic panel, lipid profile, thyroid-stimulating hormone, urinalysis, urine microalbumin, and vitamin D level.
The significant abnormal finding is the hemoglobin A1C:
| Test | Result |
|---|---|
| Hemoglobin A1C | 8.5% |
An A1C of 8.5% is above the usual treatment goal for many nonpregnant adults with diabetes and indicates inadequate long-term glycemic control. Individual A1C targets should be personalized according to factors such as age, comorbidities, hypoglycemia risk, treatment burden, and patient preferences.
The patient’s clinical presentation is most consistent with poorly controlled Type 2 diabetes mellitus.
The combination of:
Persistent fatigue
Increased thirst
Known Type 2 diabetes
Elevated A1C of 8.5%
Medication-related adverse effects
Missed follow-up
supports the need for reassessment of her diabetes treatment plan.
The patient’s blood pressure of 160/90 mmHg is another significant concern. Diabetes combined with uncontrolled hypertension increases cardiovascular and renal risk and warrants timely evaluation and management.
This is the primary diagnosis because the patient has a known history of T2DM, symptoms compatible with hyperglycemia, and an A1C of 8.5%.
The patient’s blood pressure is 160/90 mmHg despite antihypertensive therapy, suggesting suboptimal blood pressure control. Hypertension should be addressed separately because of its contribution to cardiovascular and kidney disease risk.
Hypothyroidism can cause fatigue and weight changes; however, the patient’s normal TSH makes hypothyroidism less likely as the primary explanation for her current symptoms.
The most likely primary diagnosis is poorly controlled Type 2 diabetes mellitus with inadequate glycemic control.
The patient’s uncontrolled hypertension represents an important concurrent cardiovascular risk factor and should also be addressed during follow-up.
Management should be individualized and developed collaboratively with the patient. Because medication intolerance and missed appointments may be affecting treatment success, the plan should address both clinical treatment and barriers to adherence.
Lifestyle interventions remain an important component of diabetes care. The patient should receive individualized counseling regarding nutrition, physical activity, weight management, sleep, and diabetes self-management.
Recommended strategies include:
Following an individualized, balanced eating plan
Increasing regular physical activity as tolerated
Working toward a healthy and sustainable weight
Monitoring blood glucose when recommended
Developing strategies to improve medication adherence
Maintaining adequate sleep
Addressing stress and other barriers to self-management
Participating in diabetes self-management education and support
Lifestyle recommendations should be realistic and based on the patient’s preferences, abilities, and daily routine.
Because the patient’s A1C is elevated, follow-up should include assessment of glucose patterns, medication adherence, adverse effects, and barriers to treatment.
A1C is generally assessed at least twice yearly when patients are meeting treatment goals and more frequently, such as every three months, when therapy has changed or goals are not being met.
Additional diabetes monitoring should include assessment for:
Diabetic kidney disease
Diabetic retinopathy
Peripheral neuropathy
Cardiovascular disease
Peripheral arterial disease
Foot complications
The patient’s reported diarrhea and gastrointestinal discomfort are important because medication side effects can interfere with adherence.
The patient should be educated about:
Taking medications exactly as prescribed
Recognizing symptoms of hypoglycemia and hyperglycemia
Monitoring blood glucose when instructed
Reporting persistent or severe medication side effects
Avoiding abrupt medication discontinuation without medical guidance
Understanding the purpose and timing of each medication
The current diabetes regimen should be reviewed by the prescribing clinician. If medications are poorly tolerated or insufficient to reach individualized treatment goals, alternative or additional therapies may be considered based on the patient’s cardiovascular risk, kidney function, weight-related goals, cost, preferences, and risk of hypoglycemia.
The blood pressure reading of 160/90 mmHg requires attention. The clinician should confirm blood pressure control using appropriate repeat measurements and review medication adherence, lifestyle factors, and the current antihypertensive regimen.
Because the patient has diabetes, hypertension, overweight status, and a strong family history of myocardial infarction, cardiovascular risk reduction should be an important part of her care plan.
Preventive care should be incorporated into the patient’s diabetes management plan.
Depending on age, medical history, and current screening status, care may include:
Routine diabetes follow-up
Blood pressure monitoring
Lipid assessment
Kidney disease screening
Comprehensive foot examination
Dilated retinal examination
Depression screening when clinically appropriate
Age-appropriate cancer screening
Recommended immunizations
Nutrition counseling
Diabetes self-management education and support
Cardiovascular risk assessment
Referral decisions should be based on the patient’s clinical needs.
An endocrinology referral may be appropriate if glycemic control remains difficult to achieve, medication intolerance complicates treatment, or the primary clinician needs additional support with diabetes management.
A qualified eye-care professional should perform recommended diabetic retinal screening to identify diabetic retinopathy at an early stage.
The patient should have timely follow-up to reassess glycemic and blood pressure control, medication tolerance, and adherence. A two-week follow-up can be reasonable for evaluating immediate medication and blood pressure concerns, while longer-term diabetes monitoring should include repeat A1C testing at an appropriate interval.
At follow-up, the clinician should evaluate:
Home blood glucose readings, when applicable
Medication adherence
Medication side effects
Blood pressure measurements
Lifestyle changes
Barriers to treatment
Need for medication adjustment
Preventive screening status
The most important findings in this case are the patient’s symptoms, elevated A1C, uncontrolled blood pressure, medication intolerance, and missed follow-up.
Key points include:
An A1C of 8.5% indicates inadequate glycemic control for most adults with diabetes.
Fatigue and increased thirst can occur with hyperglycemia.
A normal TSH makes hypothyroidism less likely as the primary explanation for the patient’s fatigue.
Blood pressure of 160/90 mmHg represents an important additional cardiovascular risk.
Medication side effects can contribute to poor adherence and should be addressed rather than ignored.
Diabetes management should include medication, nutrition, physical activity, monitoring, preventive care, and patient education.
Regular screening for kidney, eye, foot, neurologic, and cardiovascular complications is essential.
The primary diagnosis is poorly controlled Type 2 diabetes mellitus. The patient’s known history of T2DM, increased thirst, persistent fatigue, and A1C of 8.5% support inadequate glycemic control.
An A1C of 8.5% indicates that the patient’s average blood glucose has been above the desired range over approximately the previous two to three months. For many nonpregnant adults, this is above the usual individualized treatment goal.
When blood glucose is poorly controlled, glucose cannot be effectively used by tissues for energy. Hyperglycemia can also contribute to fluid loss and dehydration through increased urination, which may further contribute to fatigue.
Excessive thirst, or polydipsia, can occur when elevated blood glucose causes increased urinary glucose loss and fluid loss. The resulting increased need for fluids can lead to persistent thirst.
No. Hypothyroidism can cause fatigue and weight changes, but the patient’s normal TSH makes it less likely to be the primary cause in this case.
A blood pressure of 160/90 mmHg is elevated and is particularly concerning in a patient with diabetes because hypertension increases the risk of cardiovascular and kidney complications.
Monitoring should address diabetic kidney disease, retinopathy, neuropathy, cardiovascular disease, and foot complications. Regular preventive care can help identify complications before they become more severe.
Diabetic retinopathy can develop without noticeable symptoms during its early stages. Recommended retinal screening allows eye disease to be detected and managed before significant vision loss occurs.
Helpful strategies include following an individualized healthy eating plan, engaging in regular physical activity, achieving or maintaining a healthy weight, taking medications as prescribed, monitoring glucose when recommended, getting adequate sleep, and participating in diabetes self-management education.
This patient’s presentation is most consistent with poorly controlled Type 2 diabetes mellitus, supported by persistent fatigue, excessive thirst, a history of T2DM, and an A1C of 8.5%. Her blood pressure of 160/90 mmHg represents an additional concern that increases cardiovascular risk. Medication intolerance and missed follow-up appointments may be contributing to inadequate disease management and should be addressed directly.
A comprehensive approach that combines individualized pharmacologic therapy, lifestyle modification, diabetes education, cardiovascular risk reduction, preventive screening, and regular follow-up can improve glycemic control and reduce the risk of diabetes-related complications.
American Diabetes Association Professional Practice Committee. (2024). 6. Glycemic goals and hypoglycemia: Standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1), S111–S125. https://doi.org/10.2337/dc24-S006
American Diabetes Association Professional Practice Committee. (2024). 9. Pharmacologic approaches to glycemic treatment: Standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1), S158–S178. https://doi.org/10.2337/dc24-S009
American Diabetes Association Professional Practice Committee. (2024). 10. Cardiovascular disease and risk management: Standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1), S179–S218. https://doi.org/10.2337/dc24-S010
American Diabetes Association Professional Practice Committee. (2024). 11. Chronic kidney disease and risk management: Standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1), S219–S230. https://doi.org/10.2337/dc24-S011
American Diabetes Association Professional Practice Committee. (2024). 12. Retinopathy, neuropathy, and foot care: Standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1), S231–S243. https://doi.org/10.2337/dc24-S012
American Diabetes Association Professional Practice Committee. (2024). Standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1). https://diabetesjournals.org/care/issue/47/Supplement_1
U.S. Preventive Services Task Force. (2021). Screening for prediabetes and type 2 diabetes: U.S. Preventive Services Task Force recommendation statement. JAMA, 326(8), 736–743. https://doi.org/10.1001/jama.2021.12531
World Health Organization. (2024). Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes
